A 56 year old female patient was admitted to
our hospital on July 10, 2020 due to palpitation, chest tightness and
cough for more than 10 days. There was no obvious abnormality in the
laboratory examination,
including blood routine, liver and kidney function, pro-BNP, myocardial
markers, C-reactive protein, coagulation function, tumor markers, sex
hormone, rheumatism and rheumatoid factor. Chest CT indicated double
pneumonia, pericardial effusion, bilateral pleural effusion.
Echocardiography showed large left atrium with pericardial effusion.
Pathological cytology of pericardial effusion showed more mesothelial
cells, neutrophils and lymphocytes. The patient was discharged after the
effective treatment of diuresis and anti-infection.
After discharge 11 days, the patient suffered from palpitation and chest
tightness again. ECG examination showed AF (Figure 1) and the patient
was hospitalized again. No obvious abnormalities were found in routine
laboratory tests. Transesophageal echocardiography
showed that enlargement of both atrium with
mitral regurgitation and
tricuspid regurgitation (AF associated) and atrial wall thickening.
On August 5, the patient underwent AF and AFL ablation. LASSO mapping
showed that there was no potential activity in the left upper pulmonary
vein, the right upper and lower pulmonary veins, the left atrium and
left atrial appendage, but a small amount of potential in the left lower
pulmonary vein (Figure 2). The atrial activation of AFL around the
tricuspid annulus in the counterclockwise direction was mapped and part
of the right atrium showed no potential activity. Circumferential left
pulmonary veins and isthmus of tricuspid valve ablation were performed.
After AFL converted to sinus rhythm, electrophysiological examination
showed that the ablation line reached bidirectional block and AFL could
not be induced (Figure 3).
We found that no pulsation of the ablation electrode during the
circumferential left pulmonary veins ablation. So, an echocardiography
expert reviewed the previous images and the parameters. The
echocardiography indicated pericardial effusion, large left atrium, peak
A can be seen in the blood flow spectrum of the mitral valve orifice
during diastole on July 10. These results showed that the left atrium
had contraction (Figure 4A, B). However, the results of echocardiography
showed significant thickening of the wall of left atrial and left atrial
appendage on August 3, there was no peak A in the blood flow spectrum of
the mitral valve orifice during diastole. These results indicated that
the left atrial had no contraction (Figure 4C,D).